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Journal of Rural Medicine
Review
Assessment of environmental sustainability in
renal healthcare
Kei Nagai1, Hiroaki Suzuki2, Atsushi Ueda1, 3, John W. M. Agar4, and Norihiro Itsubo2
1
Department of Nephrology, Faculty of Medicine, University of Tsukuba, Japan
2
Faculty of Environmental and Information Studies, Tokyo City University, Japan
3
Department of Nephrology, Hitachi General Hospital, Japan
4
Department of Renal Medicine, University Hospital Geelong, Australia
Abstract
The health effects of climate change are becoming increasingly important; there are direct effects from heatwaves and floods, and
indirect effects from the altered distribution of infectious diseases and changes in crop yield. Ironically, the healthcare system itself
carries an environmental burden, contributing to environmental health impacts. Life cycle assessment is a widely accepted and
well-established method that quantitatively evaluates environmental impact. Given that monetary evaluations have the potential
to motivate private companies and societies to reduce greenhouse gas emissions using market mechanisms, instead of assessing
the carbon footprint alone, we previously developed a life cycle impact assessment method based on an endpoint that integrates
comprehensive environmental burdens into a single index—the monetary cost. Previous investigations estimated that therapy for
chronic kidney disease had a significant carbon footprint in the healthcare sector. We have been aiming to investigate on the envi-
ronmental impact of chronic kidney disease based on field surveys from the renal department in a hospital and several health clinics
in Japan. To live sustainably, it is necessary to establish cultures, practices, and research that aims to conserve resources to provide
environmentally friendly healthcare in Japan.
Key words: healthcare, carbon footprint, life cycle assessment, life cycle impact assessment, chronic dialysis
(J Rural Med 2021; 16(3): 132–138)
Introduction emissions; these emissions have raised the average global
temperature by 0.85% between 1880 and 20122). Experts
Recently, human-induced climate change has been iden- have examined several warming scenarios, and have fore-
tified as the greatest global health threat1). The temperature casted that the global mean surface temperature may rise
of the Earth is determined by the balance between energy between 0.3 and 4.8 °C by 21003). Alarmingly, global CO2
input from the sun, and energy lost back into space. Atmo- emissions are rising faster than the predicted worst-case
spheric gases such as water vapor, carbon dioxide (CO2), emission scenarios4). In 2018, the Intergovernmental Panel
ozone, methane, and nitrous oxides are known as greenhouse on Climate Change (IPCC) stated that annual global emis-
gases (GHGs); these GHGs are required for photosynthesis sions must be halved by 2030, and net-zero emissions must
and to warm the Earth. Industrial activities and changes to be achieved by 2050 to limit warming to 1.5°C5).
the natural landscape, such as deforestation, produce GHG Alongside the higher incidence and severity of extreme
weather events due to global climate change, heat stress
presents a real risk of death in vulnerable populations6).
Received: September 24, 2020
Ironically, the healthcare system itself carries an environ-
Accepted: February 12, 2021
Correspondence: Kei Nagai, Department of Nephrology, Faculty
mental burden that contributes to global climate change.
of Medicine, University of Tsukuba, 1-1-1 Ten-no dai, Tsukuba, Healthcare activities contribute significantly to the total
Ibaraki 305-8575, Japan national CO2 emissions, although these contributions vary
E-mail: knagai@md.tsukuba.ac.jp widely depending on the country. For example, this con-
This is an open-access article distributed under the terms of the tribution was estimated to be 10% in the United States for
Creative Commons Attribution Non-Commercial No Derivatives 2003–20137), 7% in Australia for 2014–20158), and a modest
(by-nc-nd) License . have carried out a global assessment of the wide-ranging
©2021 The Japanese Association of Rural Medicine doi: 10.2185/jrm.2020-049 | 132Journal of Rural Medicine
environmental footprint of the healthcare sector10). Studies
suggest that the enhanced activity of the healthcare sector
initiates an adverse feedback cycle by increasing the envi-
ronmental impact of healthcare (Figure 1).
Reducing GHG emissions protects human health from
the direct and indirect impacts of climate change11). It also
benefits human health through mechanisms independent of
those related to modifying climate risk; these are the health
co-benefits of mitigation12, 13). Human populations will grow,
age, and likely become more vulnerable to climate risk. As Figure 1 Cycle of climate change, disease and healthcare.
such, there is an immediate need for action to avoid worst- We propose the concept of a feedback cycle between climate
case future scenarios11). This review aims to summarize the change, an excessive disease burden, an increased need for
evidence linking health and environmental sustainability to healthcare services, and accelerated greenhouse gas emis-
help establish best practices that consider humans and the sions that increase global temperatures. Compared to the im-
planet. pact of environmental change on health, the impact of health-
care on the environment has received less attention.
Effect of Climate Change on Human
Health
Indirect effects
The principal pathways linking climate change with Climate conditions affect the risks associated with the
health may be categorized into direct and indirect mecha- transmission and distribution of diseases through vectors
nisms11, 14, 15). Direct risks are due to changes in the charac- such as mosquitoes carrying dengue or malaria24). Chang-
teristics of extreme weather events and the resulting storms, ing weather patterns are also likely to affect the incidence
floods, droughts or heatwaves. Indirect risks are mediated of diseases transmitted through infected water sources25),
by the effects of climate change on ecosystems and social such as hurricanes that result in the mixing of wastewater
structure11). The estimated impact of climate change on hu- and drinking water. This creates insufficient access to clean
man health is likely to change depending on the predicted water, potentially causing cholera26) and typhoid fever27).
future climate and socioeconomic scenarios16, 17). A previ- Changes in temperature, precipitation frequency, and air
ous study has estimated the climate-related relative risks of stagnation affect the severity of air pollution, posing sig-
health effects, and the ratio of deteriorating health alongside nificant health risks. Fine particle air pollution is estimated
climate change relative to that without climate change18). to be responsible for 4.2 million additional deaths globally
These risks are shaped by social and geographic dimen- every year, mainly due to respiratory and cardiovascular
sions, unevenly distributed across the world, and are in- diseases28). Climate change has important implications for
fluenced by socioeconomic development, technology, and livelihood, food security, and poverty as crops and livestock
health service provision1). have physiological limits in terms of health, productivity,
and survival, including those imposed by temperature. Heat
Direct effects also poses significant risks to occupational health and la-
Direct effects on human health and wellbeing result from bor productivity in areas where people work outdoors (e.g.,
rising temperatures and subsequent changes in the frequen- farmers), for long hours in hot regions29). Moreover, the high-
cy and intensity of storms19), floods20), droughts21), and heat- er frequency of droughts, floods, and other extreme weather
waves22). Although societies are adapted to local climates events impact crops and livestock yields; this means the
across the world, heatwaves represent a real risk to vulner- number of habitable areas on the planet are declining1, 5, 6).
able populations; there is a potential for significant increases Climate change-induced migration can occur through a
in risk from extreme heat under each of the predicted cli- variety of social and political pathways. This ranges from
mate change scenarios6). On an individual basis, tolerance to sea level rise and coastal erosion, to changes in extreme
any change is diminished in individuals whose capacity for weather, average precipitation and temperature, which re-
temperature homeostasis is limited by the extremes of age duces land availability and exacerbates food and water secu-
or dehydration11). Collectively, there is strong evidence for a rity issues. Although predicting the actual number of people
relationship between extreme high temperature and human to be affected by climate change continues to be a chal-
morbidity and mortality, and heat-related mortality is rising lenge, a large number of people will be forced to migrate by
as a result of climate change across a range of localities23). 205030). Climate change is considered an important factor in
exacerbating the likelihood of conflict30). Migration driven
by climate change may incur potentially severe impacts on
2021; 16(3): 132–138 | doi: 10.2185/jrm.2020-049 | 133Journal of Rural Medicine
mental and physical health through wide-ranging and com- database containing detailed information on healthcare sec-
plicated mechanisms31, 32). tors and quantified the direct and indirect environmental
damage driven by the demand for healthcare10). The study
Consequences of climate change-related health revealed that the global environmental burden from health-
effects care was between 1% and 5% of the total global burden, and
Collectively, climate change poses a clear risk to mental accounts for more than 5% of the national burden in some
illness33, 34), malnutrition35), allergies36), cardiovascular dis- countries10). In most countries, the healthcare sector had the
eases37), infectious diseases24, 26, 27, 38), injuries39), respiratory largest carbon footprint of the service sectors, and was com-
diseases28), poisoning40, 41) and renal diseases42, 43) via compli- parable in size to the food sector49).
cated mechanisms; the evidence supporting this relationship
has been progressively collected over time. Surgical sector and intensive care
Among healthcare services, the contribution of surgical
Carbon Footprint of Healthcare procedures and intensive care on the carbon footprint have
been considered. A determination of the carbon footprint
Compared to the health impacts of environmental chang- of three academic quaternary-care hospitals in Canada, the
es, the impact of healthcare on the environment has received United Kingdom and United States revealed that surgical
less attention10). The environmental footprint of the health- operating suites emitted 3.2 to 5.1 million kg of CO2e over
care sector, including air, water, and soil pollution, has un- 1 y50). Interestingly, the use of anesthetic gases and energy
intended and negative impacts on human health7). By 2009, consumption substantially contributed to the overall car-
a global movement on planetary health had been initiated, bon footprint of the healthcare sector. Another report from
and in 2015 the Lancet Commission on Health and Climate a university hospital revealed that the carbon footprint for
Change provided several recommendations1, 11), calling for: one cataract operation was 181.8 kg of CO2e51). Building and
“Support for accurate quantification of the avoided burden energy use was estimated to account for 36.1% of overall
of disease, reduced healthcare costs, and enhanced eco- emissions, while travel and procurement (including medical
nomic productivity associated with climate change mitiga- equipment) was estimated to be 10.1%, and 53.8%, respec-
tion”. Their recommendations also noted that “these will be tively51). Comparing the surgical treatment of gastric reflux
most effective when combined with adequate local capacity with medical management, the initial carbon footprint from
and political support to develop low-carbon healthy energy surgery was 1,081 kg of CO2e per patient52). This is nearly
choices”. seven times greater than the footprint of medical manage-
In light of these recommendations, there is an urgent ment; however, subsequent emissions from continuing
need to clarify the current carbon footprint of the general treatment were much lower for surgical patients (30 versus
and specific healthcare sectors. With increasing investment 100 kg of CO2e). A review of 150 procedures using lapa-
in healthcare around the world, there is considerable poten- rotomy, conventional laparoscopy or robotically associated
tial to exacerbate the harm to human health from the pollu- laparoscopy, revealed that the total carbon footprint per pa-
tion and environmental damage from this sector10). tient was 22.7, 29.2, and 40.3 kg of CO2e, respectively53). In
intensive care units, the daily carbon footprint was 178 kg
General healthcare sector of CO2e per patient with septic shock in the United States54).
The most aggressive attempt to quantify health-related Such estimates from a bottom-up inventory of items associ-
GHG emissions was undertaken by the United Kingdom ated with intense GHG emissions are important to promote
National Health Service (NHS). They used an estimate de- environmentally friendly healthcare for specific medical
rived from NHS expenditure data and supplemented this conditions.
with detailed data on building energy consumption and
travel; the complete life cycle carbon footprint of the NHS Renal treatment sector
for the 2004 calendar year was 21.3 million metric tons of Maintenance hemodialysis (HD) is a major therapy
CO2 equivalent (CO2e), which is approximately 3% of all used to save the lives of patients with end-stage renal dis-
emissions in England44). Subsequently, studies at the nation- ease. HD programs have a particularly large carbon foot-
al-scale for the United Kingdom45), United States7, 46), Cana- print, with recurrent, per capita resource consumption and
da47), Japan48), and Australia8) reported that healthcare sector waste generation profiles that are disproportionately high
emissions contributed between 4% and 10% of total GHG compared with most other medical therapies55–57). Patients
emissions in these countries; these were largely based on undergoing conventional in-center HD, with a 4 h thrice-
NHS expenditure data. Recently, international collaborative weekly regimen, were estimated to use approximately 500
studies have found that healthcare causes global environ- L of water per treatment, based on a previous survey58).
mental impacts10, 49). Researchers used a global supply-chain Moreover, this therapy was responsible for a considerable
2021; 16(3): 132–138 | doi: 10.2185/jrm.2020-049 | 134Journal of Rural Medicine
amount of waste generation and travel distance of patients a multi-region input-output (MRIO) that covers more than
and staff55, 58). As a result, annual emissions were estimated one country49). Recent worldwide research has utilized pow-
at 3.8 and 10.2 tons of CO2e per patient in the United King- erful models that include 14,847 country-sectors from 189
dom and Australia, respectively56); this is more than two- countries10).
thirds of the estimated national mean annual per capita CO2 Although there is an urgent need to assess the deteriorat-
emissions of 15.4 tons. The largest share of carbon emis- ing health, impacts, and environmental burden of the health-
sions originated from pharmaceuticals (37.5%) and medical care sector, most existing methods do not provide detailed
equipment (23.5%)56), which was consistent with findings in information on the extent of impact on humans and the en-
other sectors51). Unfortunately, despite their apparent large vironment66). This prompted the development of a methodol-
collective carbon footprint, there is very little data avail- ogy using the results of damage assessment called life cycle
able on the life cycle impacts of individual pharmaceutical impact assessment (LCIA), which has rapidly attracted at-
compounds or devices59). Beyond carbon emissions, more tention. The Life Cycle Impact Assessment Method based
comprehensive life cycle analysis is also required to iden- on Endpoint Modeling (LIME), was developed in Japan and
tify the broader environmental impacts of pharmaceuticals published in 200567); in 2015, it was updated to version 3
and devices (e.g., pollution and resource depletion during (LIME-3). This LCIA uses impact categories such as mid-
production)55). points (e.g., air and water pollution) and endpoints (e.g., hu-
man health and biodiversity), and integrates these outcomes
Life Cycle Assessment to Determine simply, through the use of a single index. Remarkably,
Precise Local Environmental Impacts LIME can evaluate the monetary index with the potential
and Damage to put pressure on companies and societies to reduce GHGs
using market mechanisms68) (Figure 2).
Life cycle assessment (LCA) is a widely accepted and
well-established method to quantitatively evaluate environ- Future Direction: An On-going Field
mental processes and products60–62). During the manufactur- Survey of the Renal Sector
ing stage, environmental impacts are assessed from raw ma-
terial extraction and processing (cradle), the manufacture, An important topic for future research is the connection
distribution, and use, to the recycling or final disposal stages between the healthcare carbon footprint, healthcare perfor-
(grave). For example, in terms of hemodialysis treatments, mance, and health outcomes49, 69). As previously discussed
the distribution of the dialysate powder concentrate from a and well-summarized in reviews57, 58), chronic dialysis thera-
factory to a dialysis unit appears to have a lower environ- py for end-stage renal disease is resource-heavy. This is par-
mental load than liquid concentrate. However, it is possible ticularly the case in remote areas because of the transpor-
that the manufacturing of highly concentrated powders re- tation of patients and medical staff, and the large amounts
quires a large amount of energy; as such, it is still unclear of pharmaceuticals and devices required. The delivery of
whether the powder or liquid concentrate is suitable for dialysis therapy also differs between countries70). From the
environment-friendly HD. Although there is little scientific environmental conservation perspective, home dialysis
evidence available on LCA in dialysis technology beyond therapy is more popular because of geographic and water
the carbon footprint study, several LCA methods have re- supply issues; this has been investigated more in Australia
cently been developed, and may be applied to the renal treat- and the United Kingdom than in Japan57, 58, 71). This provided
ment sector. the basis to examine the current reality of dialysis therapy in
National-scale studies for the United Kingdom45), the Japan, focusing on environmental problems in order to de-
United States7, 46), Canada47), Japan48), and Australia8) have velop future planet-friendly therapeutics for renal disease.
used environmentally extended input-output (EEIO) model- There is also a need for broader surveying of environ-
ing to show that healthcare sector emissions contribute to mental attitude, knowledge, and practice patterns around
the total national emissions in these countries. EEIO mod- the world; this has been undertaken in the United Kingdom
els have been widely used since the 1970s63), and underpin and Australia15, 72). Following this initiative, we established
consumption-based accounting of emissions64). An impor- a patient-based cohort with end-stage renal disease and re-
tant advantage of using EEIO modeling is that healthcare gional surveillance for patients and medical staff in a hospi-
sector emissions are estimated on a life cycle basis. This tal and several health clinics in Japan (unpublished). To the
means that estimates account for electricity, transportation best of our knowledge, this is the first attempt at an environ-
and pharmaceuticals65). Each country records emission in- mentally-themed research in the renal sector in Japan. There
ventories, monetary input-output tables, and health expen- has also been an investigation into the health consciousness
diture data. As such, differences in the assessment of emis- and pro-environmental behavior of non-specific health pro-
sions need to be corrected and used in a global scope with fessionals in a large hospital in Japan73). We aim to establish
2021; 16(3): 132–138 | doi: 10.2185/jrm.2020-049 | 135Journal of Rural Medicine
more relevant basic units of medical procedures and pro-
curement for LCIA, and ultimately develop an optimal solu-
tion for mitigating climate change and maintaining human
health and society. Additionally, popularizing a resource
conservation culture, practice, and research is necessary to
achieve environmentally friendly healthcare in Japan, given
its high healthcare and environmental burden.
Conclusion
The medical community is positioned at the forefront
of responding to the health impacts of climate change. The
health profession has the ability and the responsibility to act
as public health advocates by communicating the threats
and opportunities to the public and policy makers, and en-
suring that climate change is understood as being central
to human wellbeing14, 33). Beyond quantifying the carbon
footprint, the recently developed LCIA should be put into
Figure 2 Concise diagram of life cycle assessment and life cycle im- practice and used to evaluate the environmental burden of
pact assessment. healthcare. On-site field surveys are also beneficial towards
Most life cycle assessment studies have quantified CO2 establishing bottom-up inventory data regarding healthcare.
emissions relating to various human activities, including This data should focus on the appropriate sector and evalu-
healthcare. Beyond midpoint investigations such as carbon ate the carbon footprint, and impacts to human health and
footprint counting, life cycle impact assessment depicts the natural ecosystems.
actual impacts on humans and natural ecosystems based on
human activity and industry. Quantification of detrimental
health effects, social asset loss, destruction of biodiversity,
Acknowledgements
and reduction in productivity such as photosynthesis are in-
This article was supported in part by the Japan Society
tegrated into a single index to clearly show the environmental
burden of human activity. Monetary evaluations (e. g., yen
of the Promotion of Science (JSPS) grant no. 18KK0431 and
and dollar) have the potential to motivate private companies the Japanese Association of Dialysis Physicians grant no.
and societies to reduce greenhouse gas emissions using mar- 2019-1. We thank Dr. Kentaro Nakajima for his contribution
ket mechanisms. Abbreviations: LCA, life cycle assessment; to data collection.
LCIA, life cycle impact assessment; LIME, life cycle impact
assessment method based on endpoint modeling; DALYs,
disability-adjusted life years.
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